Placental Circulation Intact Trial (PCI-T)—Resuscitation With the Placental Circulation Intact vs. Cord Milking for Very Preterm Infants: A Feasibility Study
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Background Preterm newborns receiving briefly delayed cord clamping or cord milking at birth have better neonatal outcomes. However, the time frame in which both these procedures are performed (90% of infants receiving echographic assessments in the first 24 h) and safety variables (5 min Apgar score, delivery room intubation rate, CRIB II score, admission temperature, maximum hemoglobin concentration and hematocrit in the first 24 h and maximum serum bilirubin value) in the two study groups. We also evaluated the same safety variables in infants delivered during the study period but not recruited. Results A total of 40 infants were enrolled. In all cases the protocol was completed and all feasibility outcomes were reached. Infants assisted with an intact placental circulation have a higher 5 min Apgar score but their admission temperature was lower than milked infants. Delivery room intubation rate, CRIB II score and peak serum bilirubin value were comparable in both groups. Infants who were not subjected to a placental transfusion strategy (excluded patients) had a higher delivery room intubation rate with respect to both study groups. Conclusion Delaying cord clamping until 3 min of life was challenging but feasible and appeared to be safe. However, admission temperature must be strictly monitored and a more efficacious warming system could be implemented to prevent hypothermia during the procedure.Keywords:
Placental Circulation
Cord clamping
Neonatal Resuscitation
Apgar score
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Purpose: The Apgar-Score is used to assess the immediate neonatal adaptation to extra-uterine life in newborn infants throughout the world for over 50 years. Moreover, it allows to document the effectiveness of neonatal resuscitation. Despite that an increasing number of extremely preterm and sick newborn infants are being resuscitated due to advances in neonatal medicine, the Apgar-Score has not been adjusted. For example, there are no consistent data on the use and significance in very preterm infants. Likewise, no accepted standard for reporting a score in newborn infants undergoing resuscitation after birth exists, where many score parameters are altered by resuscitation measures. Moreover the scoring definitions in textbooks and guidelines vary substantially. The purposes of our study were the following: First to assess the interobserver variability of the Apgar-Score and second to gather more information on how the infant's maturity, breathing pattern or respiratory support and the experience of the observerthe may affect the score. Methods: 31 neonatologists, 36 obstetricians and 37 midwives looked over 20 video sequences showing delivery room resuscitations of newborn infants (gestational age 29–31 wks) in order to assign the Apgar-Score. No audio sound was performed. The heart rate was shown optically by finger tapping. Each sequence took 20 seconds. In between the sequences little breaks were interposed in order to write the scores down. Results and Discussion: Overall, this study revealed a high interobserver variability (Fig). In 15 out of 20 sequences the median value of the total Apgar-Score was the same for neonatologists and midwives. The scores given by obstetricians were tendentially lower. That may be due to the less frequent assignment of Apgar-Scores by obstetricians in general, and more particularly in preterm infants. For all observers, in the majority of sequences, heart rate showed the lowest and skin colour the highest standard deviation.
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Delayed clamping of the neonatal umbilical cord is considered beneficial to the transition to extrauterine life in a term, uncomplicated birth. However, some neonates require resuscitation and the ability to perform this is a fundamental aspect of midwifery practice. The decision to clamp and cut the umbilical cord often precludes any resuscitative attempt, but the reasoning for this action is unclear. This article explores the purpose and place of leaving the umbilical cord intact during neonatal resuscitation. It considers the physiological basis for delaying cord clamping as well as the psychological benefits to baby, mother and family of leaving the cord intact until resuscitation is complete.
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Introduction: The Neonatal Resuscitation and Adaptation Score (NRAS) was developed to address the concerns regarding how resuscitation impacts the Apgar score and how it can be accounted for in the scoring assessment.
Aims: The objective of this work was to compare between the Neonatal Resuscitation and Adaptation Score (NRAS) and the Apgar score, to determine the correlation between the two scoring systems, and their predictive ability for mortality and short-term morbidities.
Methodology: This study was a prospective cohort study. It was carried out on 410 neonates in Tanta University Hospital. Both Apgar and NRAS scores were recorded for all cases at 1st and 5th minutes of life. The scores were divided into three categories: Low (0-3), Middle (4-6), High (7-10). All neonates were followed up for 48 hours. Correlation between both scores and neonatal outcome were recorded.
Results: There was a significant positive correlation between Apgar and NRAS scores at both 1st and 5th minutes. NRAS score was more précised in discriminating neonatal admissions, mortality, need for respiratory support and morbidities than Apgar score at both 1st and 5th minutes. The regression model revealed that Apgar 5th min and both of NRAS 1st and 5th minutes were significant predictors for neonatal mortality and morbidities. The most significant predictor was NRAS 1st min.
Conclusion: Both scores can be used in assessing the neonatal condition. The most significant predictor for neonatal mortality and morbidities was NRAS 1st min.
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Immediate cord clamping (ICC), followed by immediate disconnection of an infant from its mother and subsequent relocation to a separate resuscitation platform, is the current mode of practice when respiratory support is required at birth (Hutchon and Bettles 2016). This practice is supported by a World Health Organization (WHO) (2012) guideline on basic newborn resuscitation. However, this recommendation is based upon weak evidence that was developed for hastened uterotonic drug administration, to prevent the incidence of postpartum haemorrhage (PPH) (Hutchon 2015). However, WHO (2012) continues to suggest ventilation before cord occlusion if practitioners experienced in intact cord resuscitation (ICR) are present. While midwives conduct neonatal resuscitation, they also facilitate delayed cord clamping (DCC) for at least 60 seconds, which is recommended by National Institute for Health and Care Excellence (NICE) (2014) for many documented benefits. However, compromised neonates are excluded from this (NICE 2014), and may be the population most in need of DCC during resuscitation (Hutchon 2015), as demonstrated by the stabilising haemodynamic effect of initiating ventilation before cord clamping in neonatal lambs (Bhatt et al 2013). This may provide a protective mechanism against intraventricular haemorrhage and cerebral injury, which are known risks in neonates requiring resuscitation. The aim of this work is to investigate and review ICR for term infants, in order to support ICR adoption into midwifery practice, through literature review. Studies included were publications within the past five years: quantitative studies, qualitative studies and reviews involving term or late-preterm human infants.
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Experiments have shown improved cardiovascular stability in lambs if umbilical cord clamping is postponed until positive pressure ventilation is started. Studies on intact cord resuscitation on human term infants are sparse. The purpose of this study was to evaluate differences in clinical outcomes in non-breathing infants between groups, one where resuscitation is initiated with an intact umbilical cord (intervention group) and one group where cord clamping occurred prior to resuscitation (control group).Randomized controlled trial, inclusion period April to August 2016 performed at a tertiary hospital in Kathmandu, Nepal. Late preterm and term infants born vaginally, non-breathing and in need of resuscitation according to the 'Helping Babies Breathe' algorithm were randomized to intact cord resuscitation or early cord clamping before resuscitation. Main outcome measures were saturation by pulse oximetry (SpO2), heart rate and Apgar at 1, 5 and 10 minutes after birth.At 10 minutes after birth, SpO2 (SD) was significantly higher in the intact cord group compared to the early cord clamping group, 90.4 (8.1) vs 85.4 (2.7) %, P < .001). In the intact cord group, 57 (44%) had SpO2 < 90% after 10 minutes, compared to 93 (100%) in the early cord clamping group, P < 0.001. SpO2 was also significantly higher in the intervention (intact cord) group at one and five minutes after birth. Heart rate was lower in the intervention (intact cord) group at one and five minutes and slightly higher at ten minutes, all significant findings. Apgar score was significantly higher at one, five and ten minutes. At 5 minutes, 23 (17%) had Apgar score < 7 in the intervention (intact cord) group compared to 26 (27%) in the early cord clamping group, P < .07. Newborn infants in the intervention (intact cord) group started to breathe and establish regular breathing earlier than in the early cord clamping group.This study provides new and important information on the effects of resuscitation with an intact umbilical cord. The findings of improved SpO2 and higher Apgar score, and the absence of negative consequences encourages further studies with longer follow-up.Clinicaltrials.gov NCT02727517, 2016/4/4.
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Objective: Overall, neonatal mortality has been shown to be reduced by: placental transfusion (the transfer of blood from the placenta to the neonatal circulation after birth); delayed cord clamping (DCM) (waiting for the umbilical cord to stop pulsating before clamping and cutting the cord); and umbilical cord milking (UCM) (clamping and cutting the cord immediately before milking the cord towards the neonate to expel remaining volume). This systematic review aimed to determine whether placental transfusion negatively impacts resuscitation by delaying it or has any effect on infant mortality, and to identify any barriers to performing it. Methods: CINAHL, MEDLINE, AMED and the British Nursing Index were searched using key terms to identify relevant English language publications between 2017 and 2019. Results: Five papers were selected for critical analysis—three randomised control trials and two cohort studies. Conclusion: Placental transfusion was not found to have a negative impact on neonatal resuscitation but, equally, had no significant effect on Apgar at 5 minutes; however, Apgar is a crude measure of infant mortality. The question remains around the proven multifaceted benefit of placental transfusion in the prehospital environment, which requires further research. There is evidence to suggest prehospital clinicians should be looking to change practice. Further research, considerations and consultations are required to ascertain the best way to implement the procedure with a balanced and proportionate approach considering neonatal thermoregulation and maternal management. The main reported barrier to placental transfusion was a lack of appropriate equipment.
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Background: The phenomena of transformation from the intrauterine environment to independent breathing proceeds successfully in 90% of newborns. However, timely resuscitation is crucial for the 10% remaining. Objectives: We investigated the neonate resuscitation (NR) status, predisposing factors, and outcomes. Methods: This retrospective descriptive research was conducted at Al-Zahra hospital (Guilan-Iran) between April 2018 to March 2019. During the study period, all files of born neonates were reviewed, and relevant maternal and neonate information was extracted and analyzed. Results: A total of 4,850 files were reviewed, and the data from 2,131 complete ones were analyzed. Among them, 14.1% needed resuscitation, 10.2% basic interventions, while 3.9% required advanced interventions. Neonate resuscitation outcome was significantly associated with gestational age (in less than 32 gestation weeks, 84.9% of neonates needed resuscitation) (P < 0.001), meconium staining of amniotic fluid (in 38.3% of cases whose amniotic fluid was stained with meconium, resuscitation was required) (P < 0.001), mode of delivery (in cesarean delivery, 18.7% of infants were resuscitated) (P < 0.001), birth weight (49.3% of infants weighing less than 2,500 grams needed resuscitation) (P < 0.001), multiple pregnancies (in multiple pregnancies, 66.1% resuscitation was needed (P < 0.001), Apgar score at minute 1 and 5 (in infants with an Apgar score below 7 in minute 1, 57.7% and in infants with an Apgar score below 7 in minute 5, 90.8% of neonates needed resuscitation) (P < 0.001). Conclusions: Screening pregnant women for early detection of high-risk cases and attendance of a skilled NR team at the time of delivery results in better outcomes.
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Abstract This review presents the effects of delayed umbilical cord clamping on neonatal transitional physiology. The effects of delayed cord clamping on short- and long-term neonatal outcomes are then discussed. There is ample evidence over the last 50 years that delayed cord clamping in preterm infants is beneficial for both short-term and long-term outcomes. Providing ventilation in the initial steps of neonatal resuscitation prior to clamping of the umbilical cord has a physiologic basis and results in better outcomes for newborns. The challenge now is to design equipment and strategies that can allow initial resuscitation very close to the mother while the umbilical cord is still attached to the placenta.
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